Miri’s Haven Owner Surrender Request Form

Owner Surrender Request Form

Miri’s Haven is a foster based rescue. Finding a foster/adoptive home that is a good fit for your dog is very important to us. This means that when you contact us to surrender, we will ask you to answer a series of questions so that our team can work to find an appropriate foster home for your dog. This can sometimes take time and we appreciate your patience as we go through this process. We know that this is a very difficult decision and we are here to help. Please complete all questions accurately and someone will reach out to you after we receive your answers.
Please only one dog per form. If you have multiple dogs, please complete one form for each.
Owner’s Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many dogs are you looking to surrender?
please complete a form for each dog
How soon are you looking to surrender your dog(s)?*
Why are you looking to surrender your dog?:*
Dog Name:*
Dog Age (estimate is okay):*
Dog’s birthday (if known):
Dog breed*
Dog's approximate weight*
What is your dog's gender?*
Is your dog spayed or neutered?*

YesNoI’m not sure
Is this dog current on vaccinations?*

YesI am not certainNo
Is your dog housebroken?*

HousebrokenNoWears DiapersUses Potty Pads
Does your dog currently go for leash walks or do they go out in the yard? Please describe your dogs behavior on leash:*
Can your dog do stairs?:*
e.g., pulling, aggression, slow, wants to run, etc
Is your dog crate trained?:*
Please elaborate as necessary
Where did you get the dog?:*
breeder, rescue, a gift, etc
How long have you owned this dog?:*
What is the name of your dog's vet?:*
Access to any previous medical records is very helpful
When was the last time your dog saw a vet?*
Access to any previous medical records is very helpful
Does the dog have any health problems or is currently prescribed medication?:*
Deaf, blind, arthritis etc
How often and for how long is your dog left alone?*
e.g: my dog is home alone 9 hours/day, 5 days/week.
How does your dog act when left alone? *
e.g: my dog does best when home alone in his crate, when he's not crated he cries the whole time
Has the dog ever successfully lived/interacted with dogs, cats or children? Please select all that apply*

Lived with dogLikes other dogs and has had good interactions with themIndifferent towards other dogsDoes NOT like other dogsLived with catLikes cats and has had good interactions with themIndifferent towards catsDoes NOT like catsLived with childrenLikes children and has had good interactions with themIndifferent towards childrenDoes NOT like childrenNo, they've never had any experiences with other animals or children
Is your dog friendly when meeting new people?*
If your dog has lived/frequently interacted with children, please select what age ranges the dog is comfortable with:
(Select as many as applicable)
Has your dog ever bitten a person or another animal*

NoYes
If yes, please explain*
How would you describe your dog?*

FriendlyIndependentSnugglyShyQuietBusyNervousPlayfulOther- please describe more below
Please elaborate as needed.
Does your dog have any unusual/specific habits or behaviors we should be aware of?:*
e.g: my dog only likes to take their pills in a piece of bread
Is there anything else you want to tell us about your dog?*
Please upload a few photos of your dog.*

Cancelof
Please upload a clear image of the front of your ID.*

Cancelof
How did you hear about us?*
Date:*

MonthDayYear
Should be Empty:

Owner Surrender Request Form

Please only one dog per form. If you have multiple dogs, please complete one form for each.